NURSING PROCESS: THE PATIENT WITH AN ECTOPIC PREGNANCY
The health history includes the menstrual pattern and any (even slight) bleeding since the last menstrual period. The nurse elicits the patient’s description of pains and their location. The nurse asks the patient whether any sharp, colicky pains have occurred. Then the nurse notes whether pain radiates to the shoulder and neck (possibly caused by rupture and pressure on the diaphragm).
The nurse monitors vital signs, level of consciousness, and na-ture and amount of vaginal bleeding. If possible, the nurse as-sesses how the woman is coping with the loss of a pregnancy.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Acute pain related to the progression of the tubal pregnancy
· Anticipatory grieving related to the loss of pregnancy and effect on future pregnancies
· Deficient knowledge related to the treatment and effect on future pregnancies
Based on the assessment data, major complications may include the following:
· Hemorrhagic shock
The major goals for the patient may include relief of pain; accep-tance and resolution of grief and pregnancy loss; increased knowl-edge about ectopic pregnancy, its treatment, and its outcome; and absence of complications.
The abdominal pain associated with ectopic pregnancy may be described as cramping or severe continuous pain. If the patient is to have surgery, preanesthetic medications may provide pain re-lief. Postoperatively, analgesic agents are administered liberally;this promotes early ambulation and enables the patient to cough and take deep breaths.
Patients’ distress levels vary. If the pregnancy is wanted, loss may or may not be expressed verbally by the patient and her partner. The impact may not be fully realized until much later. The nurse should be available to listen and provide support. The patient’s partner, if appropriate, should participate in this process. Even if the pregnancy was unplanned, a loss has been experienced, and a grief reaction may follow. Severe and persistent psychological dis-tress may require referral for psychological counseling.
Potential complications of ectopic pregnancy are hemorrhage and shock. Careful assessment is essential to detect the development of these complications. Continuous monitoring of vital signs, level of consciousness, amount of bleeding, and intake and output pro-vides information about the possibility of hemorrhage and the need to prepare for intravenous therapy. Bed rest is indicated. Hematocrit, hemoglobin, and blood gas levels are monitored to assess hematologic status and adequacy of tissue perfusion. Sig-nificant deviations in these laboratory values are reported imme-diately, and the patient is prepared for possible surgery. Blood component therapy may be required if blood loss has been rapid and extensive. If hypovolemic shock occurs, the treatment is di-rected toward re-establishing tissue perfusion and adequate blood volume.
If the patient has experienced life-threatening hemorrhage and shock, these complications are addressed and treated before any in-depth teaching can begin. At this time, the patient’s and the nurse’s attention is focused on the crisis, not on learning. Therefore, it may be later that the patient begins to ask questions about what has hap-pened and why certain procedures were performed. Procedures are explained in terms that a distressed and apprehensive patient can understand. The patient’s partner is included in teaching and ex-planations when possible. After the patient recovers from postop-erative discomforts, it may be more appropriate to address any questions and concerns that the patient and her partner have, in-cluding the effect of this pregnancy or its treatment on future preg-nancies. Patients should be advised that ectopic pregnancies may recur. It is important to review signs and symptoms with the pa-tient and instruct her to report an abnormal menstrual period promptly. Patient teaching is based on the needs of the patient and her partner and must take into consideration their distress and grief. The patient is informed about possible complications and in-structed to report early signs and symptoms.
Because of the risk of subsequent ectopic pregnancies, the patient is advised to seek preconception counseling before considering fu-ture pregnancies and to seek early prenatal care. Psychological sup-port and counseling may be advisable for women and their partners to help them deal with the loss of the pregnancy. Follow-up con-tact enables the nurse to answer questions and clarify information for the woman and her partner. In addition, it provides an oppor-tunity to assess their ability to cope with the loss of the pregnancy.
Expected patient outcomes may include:
1) Experiences relief of pain
a) Reports a decrease in pain and discomfort
b) Ambulates as prescribed; performs coughing and deep breathing
2) Begins to accept loss of pregnancy and expresses grief by verbalizing feelings and reactions to loss
3) Verbalizes an understanding of the causes of ectopic preg-nancy
4) Experiences no complications
a) Exhibits no signs of bleeding, hemorrhage, or shock
b) Has decreased amounts of discharge (on perineal pad)
c) Has normal skin color and turgor
d) Exhibits stable vital signs and adequate urine output
5) Levels of beta-hCG return to normal
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